Beware the Hipsterization of Cupping in Massage Therapy

Cupping gone wild. Nice try, Michael Phelps, but Gwenyth Paltrow did it first . And I tried cupping before it was cool. So there.

Before playing devil’s advocate, please know that I am ultimately pro-cupping (if it’s appropriate) and always have been. But I do not offer it as a service because I prefer working with my hands. I have received great cupping treatments which have brought me relief. I’ve also experienced painful cupping, which I did not enjoy at all and left me unnecessarily covered in purple circles without helping. And I’ve also had cupping which was meh and left me wishing someone would have just manually manipulated my tissues like I wanted. So does cupping work? Well, sometimes or maybe. And it depends. This is the only thing we can honestly say about cupping so far based on evidence and physiology. More on that later, but for now please have a look at just a tiny fraction of commentary which inspired this post:

What’s wrong with this picture? Um, EVERYTHING. The “bottom line” is LOTS of damage can occur, considering the bandwagon-ism of the other comments. Truth is we don’t know exactly why cupping appears to work and chances are many other modalities can work just as well, sans bruising. That’s fair.

Let’s be honest-er

Do I personally need evidence for everything I choose to practice? NO. Because there is not yet an answer for everything, but with a little legwork and critical thinking there is access to great working hypotheses. It is important to know the difference between a fact and a good guess. When whatever I’m doing is based on an educated guess, I clearly tell clients “I don’t know/not sure/as far as we know this could be how xyz works (or not), but I’m happy you feel better somehow”. This is being honest and clients respect that (for the record, I am guilty of having made many false claims before I knew better and was called out on them). Clients can google cupping and in 30 seconds find way more evidence against it than for it (this does not mean it does not help on some level- but the mechanisms by which it has claimed to work have been dismantled by Physiology 101 so we must move on to another hypothesis… be patient, we will get there). We are accountable for the explanations we choose to give, so let’s be honest-er.

Do I need evidence if I am going to make claims to the public about how, why, or if something works? Oh, hell yes. Otherwise, that is called making up stories and our profession needs to stop doing that if we want to move forward.

I’m all for continuing education and expanding treatment options that may work for somebody. What I’m not for is people running out and hurting their clients because the dangers of cupping are being under-touted and lost in dazzling paparazzi camera flashes. I’m also not for people spreading misinformation about when and how it may or may not work (that is in essence, lying). And lastly, I’m not for the hubris that comes along when people under-tout and misinform and are not even aware that they may be unaware (aka the Dunning-Kruger effect). Yet all of these things have happened overnight with the Phelping of cupping and it’s a little disconcerting.

Guess what? Michael Phelps was winning bucket loads of gold medals before he ever did cupping. So, maybe he’s just a great athlete and maybe cupping isn’t magic? What about all the other gold medalists who don’t employ cupping and still excel in their sports? Just pointing out the holes in this logic. With this same thinking we should also see the use of recreational cannabis explode as well; Michael Phelps smokes lots of pot, therefore, mega bong hits must be the reason behind his record-breaking gold medal collection. Does that mean we now have to become weed dealers in order to help our clients? In this New York Times article (it is one people have been citing to support the purported miraculous jene saisquoi of cupping), even Phelps’s personal trainer, Keenan Robinson, is quoted saying, “It’s just another recovery modality. There’s nothing really particularly special about it”. So let’s all slow the roll and step back a bit for the sake of ethical and safe practices.

The newest ancient sensation sweeping the nation

Literally OVERNIGHT, the price of cupping sets doubled on Amazon. Enrollment in cupping continuing ed courses has skyrocketed and so has the amount of MTs and others who now offer cupping out of the clear blue sky. Cupping has been featured front and center on every news website and even the ABMP is seizing the opportunity to wrangle up some extra CE cup-sized dollars. Laymen are cupping themselves until they implode into self-inflicted vacuums. It’s raining cups, hallelujah. Sure, this can be all good in the right hands. But what is not good are the false claims and careless practices that will burst in the Cupping Bubble of 2016. Think sub-prime mortgages, but with ancient healing cups. We all know how that ended.

Just like massage can be harmful, cupping can be harmful. Which is why I’m writing this. Our profession is full of hubris and skewed “truths” and serious massage professionals know this all too well (review the screenshot I posted up top and that’s just the tip of the iceberg). It is the sole reason why our profession is not where it could and should be. Sure, cupping may help some people sometimes, but many people have also been injured (I dare you to Google “dangers of improper cupping”). Professionals hopping on the cupping bandwagon like, “CUPPING IS THE MOST AMAZING THING EVERRRR. CUPPING WILL CURE YOU OF EVERYTHING!! CUPPINGCUPPINGCUPPING! I WILL NEVER NEED TO USE MY HANDS AGAIN, BWAHAHAHA!”, quite frankly, scare me.

Seriously, everybody chill. Cupping has been around almost as long as, well, cups. Why is it like a thing all of a sudden? Because the media has propelled the public into demanding it whether it may or may not be effective for them. And there are irresponsible practitioners beginning to do the same at an alarming rate. It’s ironic to witness an ancient practice become a modern fad that loses all respect for the art itself and laughs at science because Michael Phelps. It is CAM sensationalism at its finest. But at what cost?

Pros and cons

What do you want first? The good news or bad news? Let’s do bad first so we can end this on a positive note. Please allow me to highlight only a couple of the epic fails in cupping therapy (and there are many more which go unreported):

“Oh, but that’s fire cupping“, you say. “I would never do that”, you say. “I use the suction-cup-pump thingies which are totes safe”. Well, then allow me to show you Exhibit B: The Horrors of Improper Massage Therapy (all about suction cupping gone wrong).

If that’s not enough to convince you this can be dangerous in the wrong hands, well, you are likely one of those people that scare me. Yes, driving is statistically the safest mode of transportation, however, avoidable accidents happen every day; most often because people: A) are not paying attention, B) do not ever think it could possibly happen to them so they fail to practice basic safety precautions, or C) a combination of both A and B. If someone is not capable of acknowledging the dangers of cupping, they are in no position to proclaim its benefits. And if everyone starts pushing this like it’s the best new ice cream flavor in town, we are in big trouble.

Physiology 101

Claim: A cupping mark is not a bruise.

Truth: Indeed it is. I agree, “cupping mark” sounds much more endearing than bruise and Sweet n’ Low sounds cuter than aspartame, but under a microscope it is the same thing. Tocopheryl acetate= Vitamin E. Every research paper ever published iterates the marks are circular ecchymosis (you know what that means). Broken capillaries are exactly that: broken/disrupted capillaries. This is not to negate that cupping induced ecchymosis may have therapeutic value, but rather any such value has not been clearly defined under the existing paradigm of cupping. Also, the bruising may very well be entirely unnecessary in order to achieve results. Imagine that. It is both a cupping mark and a bruise and to deny that is to deny climate change. “But in Chinese medicine it is not a bruise, it is caused by stagnation”, you say? “It is sha“, you say? As far as I recall, actual stagnation leads to necrosis and if we aren’t referencing the same medical dictionary, this discussion will go nowhere. Call it sha or whatever you want, a bruise by any other name is still a bruise.

Claim: Cupping does not cause damage.

Truth: If that is what you believe, kindly put the cups down, walk away slowly, and never use them on anyone ever again. Please. If cupping causes capillary damage, that is by definition damage. The extent of the damage is another story, but a blanket statement of ignorance regarding the potential dangers is reason to worry. If I went for a cupping treatment and the therapist did not acknowledge this, I would not allow them to perform the treatment on me. Period. Surgeons acknowledge all the risks of a procedure before performing it. Cupping is not above a surgical procedure. We’ve already discussed the serious damages that can occur.

Claim: Cupping does not hurt.

Truth: Say whut? More accurately, cupping should not hurt. But it sure can! It’s hurt me on occasion. If someone says it hurts them, please believe them and pop that thing off. Remember do no harm? Yeah. THAT.

Claim: Cupping removes toxins.

Truth: LOL. I could leave it at lol, but that’s not productive. First of all, define the “toxins”. I’ll wait… mercury? arsenic? lead? cholera? some kind of bacteria? a skin-eating amoeba? According to the laws of the universe, there are only 2 ways actual toxins leave the human body; either poo-poo or pee-pee. That’s it. If they are able to be leeched out of someone’s skin with vacuum cups, your client is an alien species and not human. Or a frog. Maybe they’re a frog. Don’t take my word for it, read this.

Claim: Cupping improves circulation and lymphatic function.

Truth: Whoa, I’m confused. If cupping creates a bruise, sorry, I mean “cupping mark”, which is a disruption in local circulation- technically sucking blood out of the circulatory system- how is this an improvement? When I bump into a table and bruise my thigh (which happens more often than I’d like because I’m a clutz), I don’t think “Look at the improved circulation!” I understand it is minor internal bleeding, which is hardly an improvement. And as for lymphatic function, HOW? Yes, I read the explanation “suction pulls plasma and red blood cells into the tissues and up through the layers and the lymphatic system towards the surface” and I don’t understand. Blood doesn’t get sucked through the lymphatic system. I looked for evidence for this mechanism online (because this would be easily testable in a lab) and there is zero to affirm it. ZERO. Therefore, it is a false claim. I could also claim cupping helps my hair grow faster by suctioning my follicles (even though my hair grows anyway). Makes just as much sense.

If we want to give someone an accurate, ethical explanation about cupping and how it may help them, the information in this link is pretty much the only wording that does the justice. To that you may add, “let’s try and see if it helps” and proceed with care and humility. As MTs, we have to do better than just repeating inaccuracies. It is our responsibility to be clear. We can help people without making up stories and we should give our clients more credit than that. Cupping is not magic, unless of course you somehow manage to pull rabbits out of cups after a treatment, TA-DA! Then it’s magic 😉

The positives and the hope

Cupping also stimulates the mechanosensitive Aβ fibers which reduce nociceptive input. More intense stimulation activates the C and Aδ fibers in the affected areas, thereby raising the inhibitory receptive fields of cortically projecting and provoking diffuse noxious inhibitory controls. In addition, cupping probably strongly impacts relaxation and may serve as a social, comforting interaction. Further investigations of these mechanisms of action are necessary.” -Rozenfeld 2016

Now, this is a potential positive effect of cupping worth exploring! Skin deformation is something cupping has in common with many other effective modalites such as Graston technique (the Western version of GuaSha) and manual therapy. The nerve receptors which register mechanical pressure (in this case, created by the cups pulling the skin up-and-in via the vacuum effect) are stimulated in a way that inhibits nociceptive signals the brain may interpret as pain or dysfunction. Hmmmm…. see where this is going? Don’t the potential effects of cupping on the nervous system which regulates all other systems, make so much more sense than promoting unfounded claims? Could that be why people feel better afterwards? Do clients really need to be bruised for cupping to be effective?

I will leave it at that hypothesis and I do not have the answers to any of those last questions, but it is food for thought. To give credit where credit is due, I stumbled upon this better notion by reading something written by Jason Erickson (I will update this with a link whenever I find it again, but for now the reference is lost in cyberspace).

Conclusion

I like cupping! Many people do for their own reasons and there are so many skilled practitioners. What I do not like are false claims or clients being misinformed. Perform cupping with care, know its limits and potential dangers, and remember it’s ok to say “We don’t know exactly how or when this works, but if you want to try it out I will do my best. Let me know how you feel”. Is that so bad after all?